Management of Recurrent C. difficile Infection

Current Recommendations

The American Gastroenterological Association (AGA) suggests fecal microbiota-based therapies upon completion of standard antibiotic treatment for recurrent C. difficile infection 1, 2
Fecal microbiota-based therapies have shown significantly better prevention of recurrent CDI compared to controls (74.2% vs 51.7%) 3
Prevention with fecal microbiota-based therapies should be considered after the second recurrence (third episode) of CDI or in select high-risk patients 2
For immunocompetent adults with recurrent CDI, the evidence supports fecal microbiota-based therapies with a conditional recommendation based on low certainty evidence 1, 4

First-line treatment for recurrent CDI should include standard antibiotic therapy with oral vancomycin or fidaxomicin 6
Fecal microbiota-based therapies are recommended upon completion of standard antibiotics for prevention of further recurrences 1, 2
Vancomycin taper, tapered-pulsed fidaxomicin, or bezlotoxumab are reasonable alternatives for prevention of further recurrences 7
Fecal microbiota-based therapies should be given after completing antibiotics, with antibiotics ideally stopped 1-3 days before conventional FMT 2, 6

Proper diagnosis of recurrent CDI requires clinically significant diarrhea with confirmatory positive testing within 8 weeks of completing antibiotics for CDI 2
Alternative diagnoses should be considered if there are atypical symptoms or no response to vancomycin or fidaxomicin 2
Careful consideration is needed before proceeding with fecal microbiota-based therapies in patients requiring frequent or long-term antibiotics, as ongoing antibiotics may diminish efficacy 2
In severely immunocompromised patients, fecal microbiota-based therapies are not recommended 8, 6

The British Society of Gastroenterology and Healthcare Infection Society guidelines recommend FMT for patients who have had at least two recurrences of CDI 9, 10
Current guidelines make no mention of Lactobacillus reuteri (BioGaia) as a recommended treatment for recurrent C. difficile infection 1, 2, 5